Integrated anastomosis tool with graft vessel attachment device and cutting device

ABSTRACT

An integrated anastomosis tool both creates an opening in a side wall of a target blood vessel and performs an anastomosis procedure to connect a graft vessel to a side of the target blood vessel with a single integrated tool. The integrated anastomosis tool includes a cutting device, a graft vessel attachment device, an introducer, and a tool body. In each of the embodiments of the anastomosis tool, the advancement paths of a cutting device and a graft vessel attachment device cross, intersect, or align so that both the cutting device and the graft vessel attachment device can be operated by a single tool at the same intended anastomosis site in a sequential manner. The anastomosis procedure can be performed on a pressurized vessel since there is no need to interchange tools during the procedure.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a Continuation-in-part of U.S. patent applicationSer. No. 09/440,263 filed on Nov. 15, 1999 now U.S. Pat. No. 6,371,964,which is incorporated herein by reference in its entirety.

1. Field of the Invention

The invention relates to an integrated anastomosis tool with a graftvessel attachment device and a cutting device, and more particularly,the invention relates to a system and method for both creating anopening in a target blood vessel and performing an anastomosis procedurewith a single integrated tool.

2. Description of the Related Art

Vascular anastomosis is a procedure by which two blood vessels within apatient are surgically joined together. Vascular anastomosis isperformed during treatment of a variety of conditions including coronaryartery disease, diseases of the great and peripheral vessels, organtransplantation, and trauma. In coronary artery disease (CAD) anocclusion or stenosis in a coronary artery interferes with blood flow tothe heart muscle. Treatment of CAD involves the grafting of a vessel inthe form of a prosthesis or harvested artery or vein to reroute bloodflow around the occlusion and restore adequate blood flow to the heartmuscle. This treatment is known as coronary artery bypass grafting(CABG).

In conventional CABG, a large incision is made in the chest and thesternum is sawed in half to allow access to the heart. In addition, aheart lung machine is used to circulate the blood so that the heart canbe stopped and the anastomosis can be performed. During this procedure,the aorta is clamped which can lead to trauma of the aortic tissueand/or dislodge plaque emboli, both of which increase the likelihood ofneurological complications.

In order to minimize the trauma to the patient induced by conventionalCABG, less invasive techniques have been developed in which the surgeryis performed through small incisions or keyhole openings in the chestwith the aid of visualizing scopes. Less invasive CABG can be performedon a beating or stopped heart and thus may avoid the need forcardiopulmonary bypass.

In both conventional and less invasive CABG procedures, the surgeon hasto suture one end of the graft vessel to the coronary artery and theother end of the graft vessel to a blood supplying vein or artery. Thesuturing process is a time consuming and difficult procedure requiring ahigh level of surgical skill. In order to perform the suturing of thegraft to the coronary artery and the blood supplying artery the surgeonmust have relatively unobstructed access to the anastomosis site withinthe patient. In the less invasive surgical approaches, some of the majorcoronary arteries including the ascending aorta cannot be easily reachedby the surgeon because of their location. This makes hand suturing bykeyhole access either difficult or impossible for some coronary arteryand aortic sites. In addition, the conditions of some target vessels,such as heavily calcified coronary vessels, vessels having very smalldiameters, and previously bypassed vessels may make the suturing processdifficult or impossible.

Accordingly, it would be desirable to provide a sutureless vascularanastomosis device which easily connects a graft vessel to a targetvessel. Sutureless vascular anastomosis devices have been proposed suchas those described in U.S. Pat. Nos. 5,234,447; 5,695,504; 6,113,612;and 6,152,937 which allow the connection of the end of a graft vessel toa side of a target vessel without hand suturing. However, performing ananastomosis procedure with these sutureless devices still requiresclamping of the target vessel prior to formation of an incision in thetarget vessel and connection of the graft vessel to the target vessel.

U.S. Pat. No. 6,068,637 describes the combination of an intra vascularcatheter, clips, and a cutter used to perform a vascular anastomosisprocedure without the need to clamp the target vessel during theanastomosis procedure. However, this system has the drawback that thecutter is inserted through the lumen of the graft vessel. It is highlyundesirable to insert any instrument, such as the cutter, through thelumen of a graft vessel because such a procedure causes damage to theendothelial cells lining the graft vessel and associated difficulties.

Accordingly, it would be desirable to provide a sutureless vascularanastomosis device which connects a graft vessel to a target vesselwithout the need to clamp the target vessel or to pass an instrumentthrough the lumen of the graft vessel.

SUMMARY OF THE INVENTION

The present invention relates to an anastomosis tool for forming anopening in a target vessel and connecting a graft vessel to the targetvessel including a tool body, a cutting device movably attached to thetool body and having a distal end configured to form an opening in thetarget vessel, and a graft vessel attachment device movably attached totool body and having a distal end configured to connect the graft vesselto the target vessel.

In accordance with one aspect of the present invention, an anastomosistool for forming an opening in a target vessel and delivering ananastomosis device connecting a graft vessel to the target vesselincludes a graft vessel attachment device having a proximal end, adistal end, a lumen extending substantially from the proximal end to thedistal end, an axis of the lumen, and an off-axis area extending outwardfrom the lumen at a location between the proximal end and the distalend, and a cutting device slidably disposed within the lumen, thecutting device configured to extend beyond the distal end of the toolbody to form an opening in the target vessel and to move into theoff-axis area of the tool body after formation of the opening.

In accordance with an additional aspect of the present invention, adevice for forming an opening in a target vessel and delivering animplantable anastomosis device to connect a graft vessel to the targetvessel includes a tool body having a lumen for delivering an implantableanastomosis device to a target vessel, the lumen having an axis, a graftvessel attachment device movable within the lumen of the tool body fordelivering the implantable anastomosis device to the target vessel toconnect a graft vessel to the target vessel, and a cutting device forforming an opening in the target vessel substantially along the axis ofthe tool body, the cutting device being movable within the lumen of thetool body. At least one of the graft vessel attachment device and thecutting device is configured to move transversely out of the lumen.

In accordance with a further aspect of the invention, a device forforming an opening in a target vessel, delivering an implantableanastomosis device to the target vessel, and connecting a graft vesselto a target vessel, includes a cutting device configured to form anopening in the target vessel and a graft vessel attachment deviceconfigured to deliver and deploy an implantable anastomosis device toconnect the graft vessel and the target vessel. The cutting device andthe graft vessel attachment device are provided in an integral toolwhich does not pass elements through a lumen of the graft vessel.

In accordance with an additional aspect of the present invention, amethod of performing anastomosis includes providing an anastomosis toolbody having a cutting device and a graft vessel attachment devicemovable connected by the anastomosis tool body; forming an opening inthe wall of a target vessel with the cutting device; moving the cuttingdevice out of the opening in the wall of the target vessel withoutmoving the cutting device through a lumen of the graft vessel; passingthe graft vessel attachment device into the opening in the wall of thetarget vessel; and performing an anastomosis with the graft vesselattachment device.

In accordance with a further aspect of the invention, an anastomosistool for forming an opening in a target vessel and connecting a graftvessel to the target vessel includes a tool body having an opening at adistal end, a cutting device positioned in the tool body and having adistal end configured to form an opening in the target vessel. Thecutting device distal end is movable through the opening in the distalend of the tool body. A graft vessel attachment device is positioned inthe tool body and has a distal end configured to connect the graftvessel to the target vessel. At least the distal end of the graft vesselattachment device is movable through the opening in the distal end ofthe tool body.

In accordance with an additional aspect of the present invention, adevice for forming an opening in a target vessel, delivering animplantable anastomosis device to the target vessel, and connecting agraft vessel to a target vessel includes a cutting device configured toform an opening in the target vessel and a graft vessel attachmentdevice configured to deliver and deploy an implantable anastomosisdevice to connect the graft vessel and the target vessel. The cuttingdevice and the graft vessel attachment device are mechanically linked tosequentially pass the cutting device and the graft vessel attachmentdevice through a predetermined point at an anastomosis site.

BRIEF DESCRIPTION OF THE DRAWING FIGURES

The invention will now be described in greater detail with reference tothe alternative embodiments illustrated in the accompanying drawings, inwhich like elements bear like reference numerals, and wherein:

FIG. 1 is a perspective view of an integrated anastomosis tool accordingto the present invention;

FIG. 2 is a front view of the integrated anastomosis tool of FIG. 1;

FIG. 3 is a cross sectional perspective view of the integratedanastomosis tool of FIG. 1, taken along line A—A of FIG. 2;

FIG. 4 is a cross sectional perspective view of the integratedanastomosis tool of FIG. 3 with the introducer and punch in an advancedposition;

FIG. 5 is a cross sectional perspective view of the integratedanastomosis tool of FIG. 3 with the punch in a partially retractedposition;

FIG. 6 is a cross sectional perspective view of the integratedanastomosis tool of FIG. 3 with the cutting device in a fully retractedposition and the graft vessel attachment device in an advanced position;

FIG. 7 is a cross sectional perspective view of an alternativeembodiment of an integrated anastomosis tool with a cutting device andgraft vessel attachment device in retracted positions;

FIG. 8 is a cross sectional perspective view of the integratedanastomosis tool of FIG. 7 with the cutting device in an advancedposition;

FIG. 9 is a cross sectional perspective view of the integratedanastomosis tool of FIG. 7 with the cutting device in a retractedposition and the graft vessel attachment device in an advanced position;

FIG. 10 is a cross sectional perspective view of another embodiment ofan integrated anastomosis tool with a side mounted graft vesselattachment device and a cutting device in an advanced position;

FIG. 11 is a cross sectional perspective view of the integratedanastomosis tool of FIG. 10 with the cutting device in a retractedposition and the graft vessel attachment device beginning to beadvanced;

FIG. 12 is a cross sectional perspective view of the integratedanastomosis tool of FIG. 10 with the graft vessel attachment deviceadvanced;

FIG. 13A is a cross sectional perspective view of a further embodimentof an integrated anastomosis tool according to another embodiment of theinvention;

FIG. 13B is a cross sectional perspective view of another embodiment ofan integrated anastomosis tool with a pivoting introducer;

FIG. 14 is a schematic perspective view of one embodiment of a graftvessel attachment device for use in the present invention;

FIG. 15 is an enlarged perspective view of a portion of the graft vesselattachment device of FIG. 14 with an implantable anastomosis devicepositioned thereon;

FIG. 16 is a side view of a cutting device having a piercing element inside window through which the piercing element is retractable inaccordance with one embodiment of the invention;

FIG. 17 is a front view of the cutting device of FIG. 16;

FIG. 18 is a side cross sectional view of the cutting device of FIG. 16,taken along line B—B of FIG. 17;

FIG. 19 is a side view of the cutting device of FIG. 16 with thepiercing element in a retracted position;

FIG. 20 is a front view of the cutting device of FIG. 16 with thepiercing element in the retracted position; and

FIG. 21 is a side cross sectional view of the cutting device of FIG. 16with the piercing element in the retracted position.

DETAILED DESCRIPTION OF THE INVENTION

FIG. 1 illustrates an integrated anastomosis tool 10 for both creatingan opening in a side wall of a target blood vessel and performing ananastomosis procedure to connect a graft vessel to a side of the targetblood vessel with a single integrated tool. The integrated anastomosistool 10 of the present invention, shown in FIGS. 1-6, includes a cuttingdevice 12, a graft vessel attachment device 14, an introducer 16, and atool body 18. The anastomosis procedure is performed with the integratedanastomosis tool 10 on a pressurized target vessel without the need forclamping of the target vessel. The anastomosis procedure can beperformed on a pressurized vessel since there is no need to interchangetools during the procedure.

In each of the embodiments of the present invention, the advancementpaths of a cutting device and a graft vessel attachment device cross,intersect, or align so that both the cutting device and the graft vesselattachment device can both be operated by a single tool at the sameintended anastomosis site in a sequential manner. The integratedanastomosis tool 10 mechanically links the cutting device and graftvessel attachment device throughout the anastomosis procedure and allowsthe two devices to be passed sequentially to the anastomosis site. Thedevices may be separated from the tool after the procedure is complete.

The integrated anastomosis tool 10 allows the use of a single tool forboth cutting a hole in a target vessel and attaching a graft vessel tothe target vessel by sequentially advancing the cutting device 12 andthe graft vessel attachment device 14 within the tool body 18 in one ofthe methods which will be described with respect to the embodimentsillustrated in the figures. In each of the embodiments described herein,the cutting device and graft vessel attachment device are moved to theanastomosis site without passing through the graft vessel. In addition,no parts of elements of the cutting device and graft vessel attachmentdevice pass through the graft vessel preventing possible damage to thegraft vessel.

In an off-axis cutting device embodiment, illustrated in FIGS. 1-6, acutting device is moved off-axis to allow entry of the graft vesselattachment device into the target vessel. In a dual off-axis device,illustrated in FIGS. 7-9, both the cutting device and the graft vesselattachment device are movable off-axis to allow both the cutting deviceand the graft vessel attachment device to be advanced through a commonlumen or opening into the target vessel. In an off-axis graft vesselattachment device embodiment, illustrated in FIGS. 10-12, a cuttingdevice is removed along an axis of the tool while a graft vesselattachment device is advanced from an off-axis position. In Yarrangement embodiments, illustrated in FIGS. 13A and 13B, a cuttingdevice and a graft vessel attachment device are alternately advancedthrough a pivoting or stationary introducer. Although these specificmethods of sequential delivery are illustrated and described, theinvention relates to all methods of sequential delivery of a cuttingdevice and graft vessel attachment device with an integrated ormechanically linked tool.

FIG. 1 illustrates the integrated anastomosis tool 10 with the cuttingdevice 12 in an advanced position for cutting an opening in a side wallof a target vessel. The tool body 18 has a distal surface 20 with anopening 22 through which the cutting device 12 is advanced. According toone embodiment, the cutting device 12 is advanced along with theintroducer 16 and after formation of an opening in the side wall of thetarget vessel the introducer is inserted into the opening in the targetvessel. The introducer 16 maintains hemostasis during removal of thecutting device 12 and insertion of the graft vessel attachment device 14by limiting blood loss to blood contained within the tool.

The integrated anastomosis tool 10 illustrated herein has been shownwithout the advancement mechanisms for advancing and retracting thecutting device 12 and the graft vessel attachment device 14. Theadvancement mechanisms may be removably connected to the tool 10 or maybe incorporated in the tool and may be any of the known advancementmechanisms including mechanical advancing mechanisms such as screws,cams, rods, and the like; pneumatic advancing mechanisms; or any otherknown advancing mechanisms.

Referring to FIG. 3, one embodiment of a cutting device 12 is shown. Thecutting device 12 is partially advanced within the tool body 18 forcutting an opening in the target vessel. In an initial position, priorto deployment, the cutting device 12 may be completely within the toolbody 18 or partially extended through the distal opening 22 as shown inFIG. 3. The cutting device 12 includes an auger needle 26 and a circularcutter blade 28. Alternatively, the cutter blade 28 may be anon-circular continuous shape, such as an oval. The cutting device 12 isadvanced by simultaneous forward and rotary motion to the fully extendedposition illustrated in FIG. 4. As the auger needle 26 is advanced androtated into the target vessel wall, the auger grasps and holds thetissue of the target vessel wall while the circular blade 28 cuts aclean hole or opening in the target vessel wall. The plug of tissue cutby the circular blade 28 is captured on the auger needle 26 for removalwith the cutting device 12.

Surrounding the cutting device 12 is the introducer 16 which may beadvanced with the cutting device, advanced separately from the cuttingdevice, or held in place. Upon cutting of the opening in the targetvessel wall, a distal end of the introducer 16 is advanced into theopening allowing the cutting device 12 to be removed and the graftvessel attachment device to be inserted.

In the embodiment of FIGS. 1-6, the cutting device 12 and the introducer16 are mounted on a shaft 30 for longitudinal movement within the toolbody 18. After advancement of the cutting device 12 and the introducer16 to the position illustrated in FIG. 4, the introducer is held inplace by a locking mechanism (not shown) while the cutting device isretracted.

FIG. 5 illustrates the integrated anastomosis tool 10 with the cuttingdevice 12 being retracted into a storage position. The cutting device isretracted by pulling on the cutter shaft 30. The tool body 18 has arecess 32 which holds the cutting device 12 in place in the storageposition.

Once the cutting device 12 has been retracted, a clear path exists forthe graft vessel attachment device 14 to be advanced axially through theintroducer 16 to perform the anastomosis procedure. This clear path maybe referred to as the lumen of the tool and may include the path throughthe introducer 16. As shown in FIGS. 3-6 the graft vessel attachmentdevice 14 includes a shaft 36, an implantable anastomosis device 38attached to the shaft, and a graft vessel 40. The graft vessel 40extends through the shaft 36 and through the implantable device 38. Anend of the graft vessel 40 is everted over the end of the implantabledevice 38.

During the cutting of the target vessel, the graft vessel attachmentdevice 14 is contained within the tool body 18 in a chamber 44 which issubstantially axially aligned with the opening 22. The graft vesselattachment device 14 is advanced by a rod 46, as shown in FIG. 6. Theintroducer 16 includes a plurality of slits 48 which allow the distalend of the introducer to expand as the implantable device 38 passesthrough the introducer. In one embodiment, the introducer 16 is aplastic introducer with weakened lines along which the introducer splitsupon application of a force.

Upon advancement of the graft vessel attachment device 14, theimplantable anastomosis device 38 is deployed in a known manner toconnect the end of the graft vessel 40 to the side of the target vesselto achieve blood flow there between. After deployment, the integratedanastomosis tool 10 is removed from the graft vessel by sliding theentire tool 10 off of the graft vessel 40.

FIGS. 7-9 illustrate an alternative embodiment of an integratedanastomosis tool 50 in which the cutting device 12 and the graft vesselattachment device 14 are sequentially moved transversely into a commonchannel and advanced to an anastomosis site. As shown in FIG. 7, anintroducer 52 is fixed in the tool body 18 and guides the devices to theanastomosis site. Connected to a proximal end of the introducer 52 is atubular member 54 having two side slits 56, 57 for transverselyintroducing the cutting device 12 and the graft vessel attachment device14 into the tubular member. The cutting device 12 is mounted on a firstleaf spring 58 and the graft vessel attachment device 14 is mounted on asecond leaf spring 60 which are used for advancing and withdrawing thesedevices.

As shown in FIGS. 8 and 9, the cutting device 12 is first movedtransversely into the tubular member 54 through the side slit 57 andthen advanced or shuttled through the tubular member 54 and theintroducer 52 to cut a plug of tissue in the manner described above. Thecutting device 12 is removed from the tubular member 54. A ramp withinthe tubular member 54 may be used to guide the cutting device out of theside slit 57. The graft vessel attachment device 14 is movedtransversely into the tubular member and shuttled forward through thetubular member and the introducer in the same manner. In this way, thetwo devices are shuttled to and from the anastomosis site through asingle introducer 52 from an integral tool body 18.

FIGS. 10-12 illustrate an alternative embodiment of an integratedanastomosis tool 70 including a cutting device 12 which is positionedinside a tubular member 74. The cutting device 12 is advancedsubstantially axially through the tubular member 74 and an introducer 72to an anastomosis site. A graft vessel attachment device 14 of theintegrated anastomosis tool 70 is initially positioned in the tool body18 beside the tubular member 74. The tubular member 74 has a side slit76 sized to allow the graft vessel attachment tool 14 to be movedtransversely into the tubular member 74. Once the cutting device 12 hasbeen advanced to cut the opening in the target vessel and withdrawn to aposition substantially proximal of the slit 76, the graft vesselattachment device 14 is moved transversely into the tubular member 74.

The graft vessel attachment device 14 and/or the cutting device 12 inthe embodiments described above may be moved transversely in any knownmanner. For example, the graft vessel attachment device 14 of FIG. 10may be mounted on a leaf spring element 78 which permanently biases thegraft vessel attachment device toward the tubular member 74. Prior todeployment, the graft vessel attachment device 14 is retained outsidethe tubular member 74 by any known type of holding mechanism. An initiallack of alignment between the side slit 76 and the graft vesselattachment device 14 can function as a holding mechanism. After thecutting device 12 has been actuated to cut an opening in the targetvessel, it is withdrawn. Then the holding mechanism is release or thegraft vessel attachment device 14 is aligned with the side slit 76 andthe leaf spring element 78 moves the graft vessel attachment device intothe lumen of the tubular member 74 due to the bias of the spring. Theleaf spring element 78 also functions to advance the graft vesselattachment device 14 through the tubular member 74 and the introducer 72to the position illustrated in FIG. 12 for deployment of the implantableanastomosis device 38.

FIG. 13A illustrates an alternative embodiment of an integratedanastomosis tool 90 in which the cutting device 12 and the graft vesselattachment device 14 are arranged to be advanced along intersectingpaths which form a substantially Y-shape. The integrated tool 90includes an introducer 92. The tool body 18 also includes two internaldeflectors or ramps 98 for directing the cutting device 12 and the graftvessel attachment device 14 along the intersecting paths.

In operation of the integrated anastomosis tool 90 of FIG. 13A, thecutting device 12 is first advanced within the tool body 18 until adistal end of the cutting device 12 contacts the ramp 98 and is directedinto a funnel shaped proximal end 96 of the introducer 92.

FIG. 13B illustrates an alternative embodiment of the integratedanastomosis tool 90 with a Y arrangement and an introducer 92 pivotallymounted in the tool body on two pivots 94. The introducer 92 ispivotable to accommodate the different directions of advancement of thecutting device 12 and the graft vessel attachment tool 14.

In both embodiments of FIGS. 13A and 13B, after cutting the opening inthe sidewall of the target vessel with the cutting device 12, a distalend of the introducer 92 is inserted into the opening to prevent bloodloss and maintain alignment between the introducer and the opening. Thecutting device 12 is then withdrawn to a storage position outside of theintroducer 92 for advancement of the graft vessel attachment device 14.

The graft vessel attachment device 14 is advanced distally in the samemanner as the cutting device 12 to contact the ramp 98 or enter thepivoting introducer 92 and is directed through the introducer 92. Thegraft vessel is then attached to the target vessel in any known manner.

Although it is described that the introducers be inserted into theopening in the target vessel in each of the embodiments of the presentinvention, it is also possible to use the integrated anastomosis toolsdescribed herein without inserting an introducer into the opening if thecutting device and graft vessel attachment device are interchangedquickly to minimize blood loss. However, the introducer also providesthe advantage of locating the opening in the target vessel for theconnection of the graft vessel.

FIGS. 14 and 15 illustrate one exemplary embodiment of a graft vesselattachment device 100 which may be incorporated in the integrated toolof the present invention for deploying a one piece implantableanastomosis device 102. The implantable anastomosis device 102 isdeployed by the expansion of a distal linkage 104 and a proximal linkage106 to form distal and proximal flanges which trap the side wall of thetarget vessel between the flanges. The operation and deployment of thisimplantable anastomosis device is described in detail in InternationalApplication No. WO 00/69343, which is incorporated herein by referencein its entirety.

The graft vessel attachment device 14 for use in the present inventionmay be any of the known automated anastomosis systems such as those thatuse staples, sutures, one piece devices, or multi-piece devices toconnect an end of a graft vessel to an opening in a side wall of atarget vessel. Examples of other graft vessel attachment devices aredescribed in U.S. Pat. Nos. 6,179,849 and 6,206,913, in InternationalApplication No. WO 01/08601, and in the references cited therein.

FIGS. 16-21 illustrate one exemplary embodiment of a cutting device 120for use in the present invention wherein a one piece piercing element122 is movable within an introducer 124 with a circular cutting edge 126at a distal end. The piercing element 122 can be retracted by a springsteel strap 128 to a storage position within the introducer 124.

As shown in FIG. 16, the introducer 124 is bifurcated along cuts 130 toallow the introducer to expand so that a graft vessel attachment devicecan pass through the introducer. An elongated opening 132 is located onone side of the introducer 124 between the cuts 130.

As shown in FIGS. 19-21, the piercing element 122 can be retracted intothe introducer 124 by a member such as spring steel strap or cable 128which extends out of the opening 132. The piercing element 122 isslidable in a bore in the introducer 124 from an incision formingposition outside the introducer (FIGS. 13-18) to a storage position inthe opening 132 (FIGS. 19-21). With this arrangement, the strap 128holds the piercing element 122 in the forward position when it ispierced through the target vessel wall (e.g., aorta wall) and thepiercing element can then be pulled to the storage position by pullingback on the strap. With the piercing element thus pulled out of theopening 132, an anastomosis device can be delivered through the bore inthe introducer 124 to the incision site. Because the two halves of theintroducer 124 can be separated to allow radial expansion of theintroducer, the implantable anastomosis device and the deployment devicefor delivering the implantable device can be larger than the bore in theintroducer.

The term “cutting device,” as used herein, is intended to mean anyinstrument which forms an opening in a target vessel, including tissuepunches which cut a plug of tissue as shown in FIGS. 16-18, rotatabletissue cutters as shown in FIGS. 1-15, and all other tissue cutters andpunches which form an incision or opening in a target vessel. The motionof the cutting device 12 relative to the tool body 18, as describedabove, is independent of the particular embodiment of the cutting device12 that is utilized.

While the invention has been described in detail with reference to thealterative embodiments thereof, it will be apparent to one skilled inthe art that various changes and modifications can be made andequivalents employed, without departing from the present invention.

What is claimed is:
 1. An integrated anastomosis tool for forming anopening in a target vessel and connecting a graft vessel to the targetvessel, the device comprising: a tool body; a cutting device movablyattached to the tool body and having a distal end configured to form anopening in the target vessel; and a graft vessel attachment devicemovably attached to the tool body and having a distal end configured toconnect the graft vessel to the target vessel, while substantiallysealing against the target vessel; wherein the graft vessel attachmentdevice is movable substantially along a first direction and the cuttingdevice is movable both transverse to the first direction andsubstantially along the first direction.
 2. The tool of claim 1, furthercomprising: an implantable anastomosis device operatively coupled to thegraft vessel attachment device.
 3. The tool of claim 1, wherein thecutting device is a tissue punch.
 4. The tool of claim 1, wherein thecutting device includes a circular cutting element.
 5. The tool of claim1, wherein both the graft vessel attachment device and the cuttingdevice are movable along a first direction and movable transverse to thefirst direction.
 6. The tool of claim 1, wherein both the graft vesselattachment device and the cutting device are contained within the toolbody simultaneously.
 7. An integrated anastomosis tool for forming anopening in a target vessel and connecting a graft vessel to the targetvessel, the device comprising: a tool body; a cutting device movablyattached to the tool body and having a distal end configured to form anopening in the target vessel; and a graft vessel attachment devicemovably attached to the tool body and having a distal end configured toconnect the graft vessel to the target vessel, while substantiallysealing against the target vessel; wherein the cutting device is movablealong a first direction and the graft vessel attachment device ismovable along a second direction non-parallel to the first direction. 8.An integrated anastomosis tool for forming an opening in a target vesseland connecting a graft vessel to the target vessel, the devicecomprising: a tool body; a cutting device movably attached to the toolbody and having a distal end configured to form an opening in the targetvessel; and a graft vessel attachment device movably attached to thetool body and having a distal end configured to connect the graft vesselto the target vessel, while substantially sealing against the targetvessel; wherein the cutting device is movable substantially along afirst direction and the graft vessel attachment device is movable bothtransverse to the first direction and substantially along the firstdirection.
 9. An anastomosis tool for forming an opening in a targetvessel and delivering an anastomosis device connecting a graft vessel tothe target vessel, the device comprising: a graft vessel attachmentdevice having a proximal end, a distal end, a lumen extendingsubstantially from the proximal end to the distal end, an axis of thelumen, and an off-axis area extending outward from the lumen at alocation between the proximal end and the distal end; and a cuttingdevice slidably disposed at least partially within the lumen, thecutting device configured to extend beyond the distal end of the toolbody to form an opening in the target vessel and to move into theoff-axis area of the tool body after formation of the opening.
 10. Thetool of claim 9, further comprising: an implantable anastomosis deviceoperatively coupled to the graft vessel attachment device.
 11. The toolof claim 10, wherein the implantable anastomosis device is movablethrough the lumen when the cutting device is moved into the off-axisarea.
 12. The tool of claim 9, wherein the cutting device is a rotatablecutter.
 13. The tool of claim 9, further comprising a spring memberconnected to the cutting device for moving the cutting device from thelumen of the tool into the off-axis area.
 14. The tool of claim 9,wherein the cutting device is configured to move through a side openingto a storage position in the off-axis area in the tool.
 15. The tool ofclaim 9, wherein the cutting device includes a circular cutting element.16. A device for forming an opening in a target vessel, delivering animplantable anastomosis device to the target vessel, and connecting agraft vessel to a target vessel, the device comprising a cutting deviceconfigured to form an opening in the target vessel and a graft vesselattachment device configured to deliver and deploy an implantableanastomosis device to connect the graft vessel and the target vessel,the cutting device and the graft vessel attachment device being providedin an integral tool which does not pass elements through a lumen of thegraft vessel.
 17. The device of claim 16, wherein the cutting device isconfigured such that the cutting device is not separated from the graftvessel attachment device after forming the opening in the target vessel.18. The device of claim 16, wherein the cutting device includes acircular cutting element for cutting a plug of tissue.
 19. The device ofclaim 16, wherein the cutting device and the graft vessel attachmentdevice are configured to move sequentially through a single opening in adistal end of the device.
 20. The device of claim 19, wherein thecutting device moves along a first path and the graft vessel attachmentdevice moves along a second path, the first and second pathsintersecting substantially at an anastomosis site.
 21. A method ofperforming anastomosis comprising: providing an anastomosis tool bodyhaving a cutting device and a graft vessel attachment device movablyconnected to the anastomosis tool body; forming an opening in the wallof a target vessel with the cutting device; moving the cutting deviceout of the opening in the wall of the target vessel without moving thecutting device through a lumen of the graft vessel; passing the graftvessel attachment device into the opening in the wall of the targetvessel; and performing an anastomosis with the graft vessel attachmentdevice.
 22. The method of claim 21, wherein the step of moving thecutter device out of the opening in the target vessel includes storingthe cutting device at a storage position in the anastomosis tool body.23. The method of claim 21, wherein the step of moving the cuttingdevice out of the opening in the target vessel includes moving thecutting device transversely with respect to an insertion path of thecutting device.
 24. The method of claim 21, wherein the step of formingan opening in the wall of the target vessel with the cutting deviceincludes punching the tissue of the wall of the target vessel.
 25. Themethod of claim 21, wherein the step of forming an opening in the wallof the target vessel with the cutting device includes cutting a plug oftissue with a circular cutting blade.
 26. The method of claim 21,wherein the step of forming an opening in the wall of the target vesselwith the cutting device includes advancing the cutting device and anintroducer into the target vessel, and retaining the introducer in theopening in the target vessel while the cutting device is moved out ofthe opening in the target vessel.
 27. The method of claim 26, whereinthe graft vessel attachment device is passed into the opening in thewall of the target vessel through the introducer.
 28. The method ofclaim 26, wherein the introducer provides hemostasis when retained inthe opening.
 29. The method of claim 26, wherein the introducer andcutting device enter the target vessel substantially simultaneously.